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Data Elements
Data elements sent to NC DETECT from emergency departments, the Carolinas
Poison Center data and the Pre-hospital Medical Information System data
are detailed in three separate tables below.
Emergency Department Data
Data elements listed below are collected by NCHESS,
although Triage Note is currently an optional element and hospitals are
not required to send it.
Inclusion Criteria for NCHESS Case Reporting: Patients treated in the
participant ED regardless of their disposition and patients Triaged who
then leave AMA or without being seen. Also patients treated in the ED
and then admitted to the hospital should be included.
Exclusion Criteria for NCHESS Case Reporting: Patients triaged away to
a clinic or directly admitted to an inpatient unit.
| Emergency Department Data Elements Typically Available in NC DETECT Line Listing Reports |
Name |
Description/Notes |
Internal Tracking ID |
NC DETECT-generated identifier that uniquely identifies a patient at that healthcare facility/system. Can be used to track repeat visits by the same patient to the same facility/system |
Patient Age |
Available in years |
Sex |
M (Male), F (Female), U (Unknown) |
Patient City |
Patient’s city of residence |
Patient County |
Patient’s county of residence |
Patient ZIP |
Patient’s ZIP of residence (5-digit) |
Patient State |
Patient’s state of residence |
Visit ID |
NC DETECT-generated identifier that uniquely identifies that ED visit |
Hospital |
Emergency department facility where patient sought care |
Insurance Coverage (or Other Expected Source of Payment) |
Entity or person expected to be responsible for patient's bill for this ED visit (private insurance, self-pay, Medicare, Medicaid, etc.) |
Arrival Date and Time |
First date and time documented in patient's record for this ED visit |
Transport Mode |
Patient's mode of transport to ED (walk-in, ground ambulance, etc.) |
Chief Complaint |
Patient's reason for seeking care or attention, expressed in terms as close as possible to those used by patient or responsible informant |
Triage Notes |
Supporting information for Chief Complaint |
Blood Pressure |
Blood pressure taken at triage (when available) |
Initial Temperature |
Temperature taken at triage (in Celsius) |
Injury Code(s) |
Encoded description of injury event that precipitated patient's ED visit; ICD-9-CM E code(s) |
Disposition |
Patient's anticipated location or status following ED visit (discharged, admitted, transferred, died, etc.) |
Disposition Diagnosis Description |
Practitioner's description of condition or problem for which services were provided during patient's ED visit, recorded at time of disposition |
Diagnosis Code(s) |
Up to 11 ICD-9-CM Final Diagnosis Codes |
Carolinas Poison Center (CPC) Data Elements
The Carolinas Poison Center (CPC) is the designated Statewide Poison Control Center for North Carolina and certified as a Regional Poison Control Center by the American Association of Poison Control Centers. CPC is an emergency telephone resource of poisoning information, staffed 24 hours a day, seven days a week, by registered nurses and pharmacists (specialists in poison information) who are specially trained to provide diagnostic and treatment advice for acute and chronic poisonings to the public and healthcare professionals.
CPC receives over 120,000 calls per year. More information is available at http://www.ncpoisoncenter.org/.
| CPC Data Elements Sent to NC DETECT |
Data Element |
Description |
Call Date and Time |
Date and time of call to CPC |
Call Type |
Call type listed as exposure, information or drug identification |
Call Type Category |
Subcategories for information call types |
Caller City |
City where call was made |
Caller County |
County where call was made |
Caller Location Code |
Zip code or area code/exchange of caller |
Caller Site |
Location of caller at initial call (residence, workplace, etc.) |
Caller State |
State where initial call was made |
Caller Zip |
Zip code where call was made |
Case Number |
Unique number for patient |
Chronicity |
Records exposure as acute or chronic |
Clinical Effects |
9 categories of clinical effects (cardiovascular, dermal, gastrointestinal, hematologic/hepatic, neurological, ocular, renal/genitourinary, respiratory, and miscellaneous). Each clinical effect is recorded as no effect, related, not related, or unknown if related |
Duration of Effect |
Duration of clinical effects |
Exposure Duration |
Duration of chronic exposures |
Exposure Reason |
Type of exposure if call type was an exposure call |
Exposure Site |
Location of the patient when the exposure occurred |
Final Health Care Facility |
Type of health care facility for patients transferred from the initial HCF to a second HCF |
Follow up Number |
Number of follow-up contacts for each patient |
Initial Health Care Facility |
Type of health care facility patient is in or referred to |
Medical Outcome |
Final outcome of patient after final follow-up |
Multiple Patients? |
Yes/No |
Patient Age |
|
Patient Age Group |
|
Patient Gender |
|
Patient Pregnancy Duration |
Number of weeks pregnant |
Product ID |
Identifier for product involved in call |
Related Case Number |
Case number of primary case/call related to patient |
Route |
Exposure Route: Aspiration, Bite, Dermal, Ingestion, Inhalation, Ocular, Other, Otic, Parenteral, Rectal, Unknown, Vaginal |
Scenarios |
7 categories of possible exposure scenarios (dosing/therapeutic error, vapor/fume problems, child-resistant closure on product, access to product, confusion about product, pesticide problems, miscellaneous). Up to four scenarios can be selected per case |
Substances |
Information on all substances involved in exposure |
Therapies |
2 categories of therapy provided (decontamination or other). Each therapy is recorded as not recommended, recommended, performed, recommended and performed, or recommended, known not performed. |
Pre-hospital Medical Information System (PreMIS) Data
Elements
The Prehospital Medical Information System (PreMIS) is an internet based EMS information system. The PreMIS system provides a data entry and reporting capability for the evaluation of EMS patient care and system performance. The system is in use by over 800 EMS agencies, 40,000 technicians, and maintains over 1,000,000 records per year. More information is available at http://www.emspic.org.
| PreMIS Data Elements available in NC DETECT reports |
Data Element |
Description / Notes |
Agency county |
EMS Agency county |
Agency name |
EMS Agency name |
Anatomic location |
Pick list: Abdomen, Back, Chest, Extremity-Lower, Extremity-Upper, General/Global, Genitalia, Head, Neck |
Chief complaint |
Free-text narrative of the patient's chief complaint, as close as possible |
Destination Name |
|
Destination Type |
|
Dispatch complaint |
Abdominal Pain, Allergic Reaction, Animal Bites, Assault, Back Pain, Breathing Problems, Burns, Carbon Monoxide/Inhalation, Cardiac/Respiratory Arrest, Chest Pain, Choking, Convulsions/Seizure, Diabetic Problem, DOA, Drowning, Electrocution, Eye Problem, FALLS/Back Injury, FIRE, HAZARDOUS MATERIAL, Headache, Heart Problems, Heat/Cold Exposure, Hemorrhage/Laceration, Industrial/Machinery Accidents, Ingestion/Poisoning, LIFE LINE, OVERDOSE/POISONING, Pregnancy/Childbirth, PSYCHIATRIC/SUICIDE, SEIZURES, Sick Person, Stab/Gunshot Wound, STANDBY/SPECIAL EVENT, STROKE, SUBSTANCE ABUSE, Traffic Accident, TRANSPORT, Traumatic Injuries, Unconscious, Unknown Problem/Man Down, Transfer/Interfacility/Palliative Care, MCI |
Incident address |
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Incident city |
|
Incident Disposition |
Treated, Refused, Dead. EMS calls with an incident disposition of Cancelled, No Treatment Required, or No Patient Found are not sent to NC DETECT. |
Incident Facility Code |
|
Incident Location Type |
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Incident state |
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Incident zip code |
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Mass casualty |
Yes/No |
Patient address city |
|
Patient address state |
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Patient address zip code |
|
Patient age |
|
Patient age unit (Years, Months, Days, Hours) |
|
Patient birth date |
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Patient Destination date and time |
|
Patient gender |
|
Patients at scene |
single or multiple |
Primary symptom name |
Pick list: Bleeding, Breathing Problems, Change in Responsiveness, Choking, Death, Device/Equipment Problem, Diarrhea, Drainage/Discharge, Fever, HEADACHE, Malaise, Mass/Lesion, Mental/Psych, MENTAL STATUS CHANGE, Nausea/Vomiting, NONE DETECTED, Pain, Palpitations, Rash/Itching, Swelling, Transport Only, Weakness, Wound |
Provder Primary Impression |
|
Provider Secondary Impression |
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Secondary complaint |
Free-text narrative of the patient's secondary complaint(s), as close as possible a quote from the patient |
Secondary symptom name |
See Primary Symptom Name |
Unit notified timestamp |
|
Vital Signs: Blood pressure, Temperature, pulse oximetry, respiratory rate |
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Work related |
Yes / No / Not Recorded |
Revised 11/9/2011
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